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https://upload.orthobullets.com/topic/5009/images/aaos type 2 acetabular.jpg
https://upload.orthobullets.com/topic/5009/images/aaos type iii acetabular..jpg
https://upload.orthobullets.com/topic/5009/images/aaos pelvic discontinuity.jpg
https://upload.orthobullets.com/topic/5009/images/paprosky 1 acetabulum.jpg
https://upload.orthobullets.com/topic/5009/images/paprosky 2a acetabulum.jpg
  • Summary
    • THA Revision is most commonly performed to address aseptic loosening, fracture, instability, or infection associated with a prior THA. 
    • Diagnosis and etiology of THA failure can be determined by a combination of physical examination, labs, and hip radiographs.
    • Treatment depends on etiology of failure, prior surgery and patient activity demands. 
  • Epidemiology
    • Incidence
      • in the United States is projected to increase >100% by 2030
    • Demographics
      • roughly equal male to female
      • average age of roughly 65-70 in most studies
  • Etiology
    • Pathophysiology
      • femoral component failure
      • acetabular component failure
      • both component failure
      • neither
    • Indications
      • wound healing complications
      • periprosthetic fracture
      • implant fracture
      • periprosethic joint infection (PJI)
      • adverse local soft tissue reaction (MoM)
      • trunnionosis
      • aseptic loosening
      • limb length discrepancy (LLD)
    • Broad categories
      • revision surgery without affecting modular OR nonmodular components
        • revision wound closure
        • psoas release
        • heterotopic bone excision
        • ORIF of periprosthetic fracture
      • revision surgery affecting modular components only
        • femoral head and or polyethyelene exchange
        • titanium sleeve
      • revision surgery nonmodular components
        • acetabular component exchange
          • most common reason for revision in the Charnley "low-friction" total hip arthroplasty
        • femoral component exchange
        • removal of both components
          • replaced with new components
          • replaced with antibiotic spacer
          • girdlestone
  • Classification of Bone Loss
    • Acetabulum
      • AAOS Classification of Acetabular Bone Loss
      • Type I (segmental)
      • Loss of part of the acetabular rim or medial wall
      • Type II (cavitary)
      • Volumetric loss in the bony substance of the acetabular cavity
      • Type III (combined deficiency)
      • Combination of segmental bone loss and cavitary deficiency
      • Type IV (pelvic discontinuity)
      • Complete separation between the superior and inferior acetabulum
      • Type V (arthrodesis)
      • Arthrodesis
      • Paprosky Classification of Acetabular Bone Loss
      • Type I
      • Minimal deformity, intact rim
      • Type IIA
      • Superior bone lysis with intact superior rim
      • Absent superior rim, superolateral migration
      • Type IIC
      • Localized destruction of medial wall
      • Type IIIA
      • Bone loss from 10am-2pm around rim, superolateral cup migration
      • Type IIIB
      • Bone loss from 9am-5pm around rim, superomedial cup migration
    • Femur
      • AAOS Classification of Femoral Bone Loss
      • Type I (segmental)
      • Loss of bone of the supporting shell of femur
      • Type II (cavitary)
      • Loss of endosteal bone with intact cortical shell
      • Type III (combined)
      • Combination of segmental bone loss and cavitary deficiency
      • Type IV (malalignment)
      • Loss of normal femoral geometry due to prior surgery, trauma, or disease
      • Type V (stenosis)
      • Obliteration of the canal due to trauma, fixation devices, or bony hypertrophy
      • Type VI (femoral discontinuity)
      • Loss of femoral integrity from fracture or nonunion
      • Paprosky Classification of Femoral Bone Loss
      • Type I
      • Minimal metaphyseal bone loss
      • Type II
      • Extensive metaphyseal bone loss with intact diaphysis
      • Type IIIA
      • Extensive metadiaphyseal bone loss, minimum of 4 cm of intact cortical bone in the diaphysis
      • Type IIIB
      • Extensive metadiaphyseal bone loss, less than 4 cm of intact cortical bone in the diaphysis
      • Type IV
      • Extensive metadiaphyseal bone loss and a nonsupportive diaphysis
  • Presentation
    • Symptoms
      • groin pain --> acetabulum
      • thigh pain --> femoral stem
      • start-up pain --> component loosening
      • night pain --> infection
      • no improvement in pain after surgery --> incorrect diagnosis
    • Physical exam
      • inspection
        • assess wound for infection
        • gait
        • external rotation of the affected extremity
          • present with femoral stem subsidence 
            • femoral stems most commonly subside in retroversion 
      • range of motion
        • in flexion, extension, abduction looking for restriction of motion or pain
          • avoid positions of dislocation based on THA approach
      • provocative test
        • pain with resisted hip flexion suggests psoas impingement
  • Imaging
    • Radiographs
      • recommended views
        • AP pelvis
        • orthogonal views of involved hip
        • full-length femur radiographs
      • opitional views
        • pre-operative radiographs
        • immediate post-operative radiographs
        • Judet views
          • useful for assessment of columns
    • CT scan
      • indications
        • useful for determining extent of osteolysis
          • radiographs frequently underestimate extent of osteolysis
        • angiogram to determine relationship to neurovascular structures with Paprosky IIIB defects
        • assessment of component position
  • Studies
    • Serum labs
      • infectious laboratories
        • ESR
        • CRP
        • CBC
      • metal levels
        • cobalt and chromium levels
          • trunnionosis
          • THA pseudotumor
    • Aspiration
      • recommended if infectious laboratories are suggestive of infection
  • Treatment
    • Nonoperative
      • indications
        • differing etiology of pain (i.e. back pain, greater trochanteric bursitis, etc.)
        • no identifiable etiology of pain
    • Operative
      • Femoral revision
        • primary total hip arthroplasty components
          • indications
            • minimal metaphyseal bone loss, Paprosky I
        • uncemented extensively porous-coated long-stem prosthesis (or porous-coated/grit blasted combination) or modular tapered stems
          • indications
            • most Paprosky II and IIIa defects; Paprosky IIIb (modular fluted tapered stem)
          • outcomes
            • 95% survival rate at 10-years
        • femoral impaction bone grafting
          • indications
            • large ectactic canal and thin cortices
            • Paprosky IIIb and IV defects
          • outcomes
            • most common complication is stem subsidence
        • allograft prosthetic composite (APC)
          • indications
            • Paprosky IIIb and IV defects
        • endoprosthetic replacement (EPR)
          • indications
            • massive bone loss with a non-supportive diaphysis
            • Paprosky IIIB and IV defects
        • cemented stems
          • indications
            • irradiated bone
            • elderly with severe osteopenia
            • Dorr C femur
          • outcomes
            • high failure rate
      • Acetabular revision
        • porous-coated hemisphere cup or jumbo secured with screws
          • indications
            • at least 50% of bone stock present to support cup
          • disadvantage
            • jumbo cup may disrupt posterior column with additional bone reamed
            • dislocation
        • porous-coated hemispherical cup with acetabular augments
          • indications
            • bone loss (Paprosky defects Type IIB-C and IIIA-B)
          • outcomes
            • 2 year survivorship 94%-100%
            • 5 year survivorship 92%-100%
            • 10 year survivorship 92%
        • reconstruction cage with structural bone allograft
          • indications
            • rim is incompetent (<2/3 of rim remaining), <50% of bone stock present
          • outcomes
            • allograft failure is the most common complication
            • high failure rate (40-60%) without reconstruction cage due to component migration after graft resorption
        • custom triflange cup
          • indications
            • pelvic discontinuity
        • cemented acetabular components
          • can cement a liner by itself or into a well fixed cup
        • liner options
          • e.g. face changing, oblique, lipped, offset, contrained, dual mobility, etc.
      • Combined revision
        • femoral head and polyethylene exchange
          • indications
            • eccentric wear of the polyethylene with stable acetabular and femoral components
            • acute infection
            • trunnionosis
          • outcomes
            • hip instability is the most common complication of isolated liner exchange
        • conversion from a hip arthrodesis
          • indications
            • low back and knee pain as a result of arthrodesis
          • outcomes
            • implant survival greater than 95% at 10 years
            • competence of abductor and gluteal musculature is predictive of ambulatory success
            • improved ipsilateral knee and back pain
      • Revision without changed modular or nonmodular components
        • ORIF periprosthetic fracture
          • indications
            • fracture with stable components
        • psoas release
          • indications
            • painful psoas with clinical signs of impingement and improvement with lidocaine injection
            • can be completed arthroscopically
        • heterotopic bone excisions
          • indications
            • mature heterotopic bone formation causing pain and restricted range of motion
  • Surgical Techniques
    • Femoral revision
      • primary total hip arthroplasty components
        • technique
          • must be sure there is no unexpected bone loss
      • uncemented extensively porous-coated long-stem prosthesis or modular tapered stems
        • technique
          • removal of stem may require extended trochanteric osteotomy (ETO)
            • ETO decreases load to failure (fracture)
          • femoral stem must bypass most distal defect by 2 cortical diameters
            • prevents bending moment through cortical hole
          • cavitary lesions are grafted with particulate graft
          • allograft cortical struts or plates may be used to reinforce cortical defects
      • femoral impaction bone grafting
        • technique
          • morselized fresh-frozen allograft packed into canal
          • smooth tapered stem cemented into allograft
      • allograft prosthetic composite (APC)
        • technique
          • measure host canal size, allograft canal size should be slightly larger than distal host canal
          • mark rotation and make femoral osteotomy (transverse or step) cut on host bone
          • allograft is prepared (usual neck cut and canal reamining) for cementing of fully porous-coated stem
          • host femur is prepared with straight reamers with goal of 4-6cm of good scratch fit distal to osteotomy
          • component is cemented into allograft and press fit into host bone
      • endoprosthetic reconstruction (EPR)
        • technique
          • a sample of bone from distal femoral osteotomy should be sent for frozen section to confirm no tumor cells are present prior to instrumenting
          • option for distal fixation include a cemented stemmed endoprosthesis, compressive osseointegration, or a press-fit fully porous-coated cylindrical stem
      • cemented stems
        • technique
          • bone grafting of any femoral defects prior to cementing
          • ensure canal preparation has removed old cement, neocortex (greater and less troch), and sclerotic bone for cement interdigitation
          • may require extended trochanteric osteotomy with difficult cement mantle/spacer removal
    • Acetabular revision
      • porous-coated hemisphere cup or jumbo secured with screws
        • technique
          • cavitary lesions are filled with particulate graft
          • cup placement should be inferior and medial
            • lowers joint reactive forces
          • metallic wedge augmentation may be used if cup in good position and rigid internal fixation is achieved
          • jumbo cups may be used when larger reamer is needed to make cortical contact
          • structural allografts may be used to provide stability while bone grows into cementless cup
      • porous-coated hemispherical cup with acetabular augments
        • technique
          • gentle reaming to smooth the acetabulum and minimizing the removal of good supportive bone
          • assess cup size with trials and location for augments
          • fix the augment with screws
          • place small amount of cement on the augment and place real cup to unite the augment to the cup
          • place screws in the cup, goal is to have a screw go through the cup and augment
      • reconstruction cage and structural bone allograft
        • technique
          • polyethylene cup is cemented into reconstruction cage
          • bone graft placed behind cage
      • custom triflange
        • technique
          • sterilize custom triflanged acetabular component (CTAC) model for intraopeative reference
          • removal of prior implant and assess needed excess bone removal
          • place iliac flange first followed by pubic and ischial flange
          • secure with screw fixation
          • consider placement of posterior column plate
      • cemented cup
        • technique
          • cement polyethylene into stable cup
    • Combined revision
      • Femoral head and polyethylene exchange
        • technique
          • exchange both head and liner
          • osteolytic defects may be bone grafted through screw holes to fill bony defects
      • Conversion from hip arthrodesis
        • technique
          • osteotomy of remaining greater trochanter
          • femoral neck ostoetomy and acetabular reaming can be done under radiographic guidance given limitations in bony landmarks
          • consideration for revision cup and femoral stem as well as dual mobility or constrained liner given high dislocation rate
          • if abductor deficiency can perform glut max transfer
            • along with the tensor fascia lata, the anterior aspect of the gluteus maximus is freed and transferred to the greater trochanter so that the fibers are similarly oriented to the native abductor musculature
    • Revision without changed modular or nonmodular components
      • ORIF periprosthetic fracture
        • technique
          • assess stability of components, if stable treat fracture and if unable revise
          • see topic page
      • psoas release
        • technique
          • see topic page
      • heterotopic bone (HO) excision
        • technique
          • await maturation of bone
          • excision of bone should be followed by HO prophylaxis of either NSAIDs, radiation, or both.
  • Prognosis
    • Lower mid-term and long term survival compared to primary THA with higher rates of complications
      • dislocation (even in simple procedures)
      • infection
      • nerve palsy
      • fractures
      • abductor deficiency
      • DVT
      • limb length discrepancy
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